2021 benefit summary
TRANSCRIPT
2021Benefit Summary
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Medical & Dental BenefitsAdministered by Cigna
HMO PPO + HSA PPO (Open Access Plus)In-Network In-Network In-Network
Medical Deductible (Single/Family) $0 $1,400/$2,800 $250/$500
Medical Out-of-Pocket Max (Single/Family) $2,000/$4,000 $2,800/$5,600 $2,000/$4,000
Rx Out-of-Pocket Max (Single/Family) $1,000/$2,000 Medical Plan Max Applies $1,000/$2,000
Preventive Services No charge No charge No chargeOffice Visit $20 copay Deductible, then 10% $15 copaySpecialist Visit $20 copay Deductible, then 10% $15 copay
Prescription Drugs 30-Day Retail 90-Day Mail 30-Day Retail 90-Day Mail 30-Day Retail 90-Day Mail
Generic Drugs - Tier 1 $10 copay $20 copay $15 copay $30 copay $10 copay $20 copayPreferred Brand Drugs - Tier 2 $20 copay $40 copay $40 copay $80 copay $20 copay $40 copayNon-Preferred Brand Drugs - Tier 3 $40 copay $80 copay $60 copay $120 copay $40 copay $80 copay
¹ Reflects In-Network benefits only.² Prescription Drugs subject to deductible.
Cigna DHMOIn-Network
Deductible (Single / Family)
None
Calendar Year Max NonePreventive Services Covered 100%Basic Services Charges vary by serviceMajor Services Charges vary by serviceOrthodontia Charges vary by service
Cigna Dental PPOIn-Network Out-of-Network1
Deductible (Single / Family) $50/$150
Calendar Year Max $3,000Orthodontic Lifetime Maximum $2,000
Preventive Services No chargeBasic Services Plan: 90% ; Member: 10%Major Services Plan: 60% ; Member: 40%Orthodontia Plan: 50% ; Member: 50%
This is not a complete explanation of benefits. The actual plan brochure with complete details is available upon request.
*The information contained herein is subject to the disclosures and disclaimers on the final page of this report/proposal/review.
Vision InsuranceAdministered by EyeMed
EyeMed Vision*Service AvailabilityEye Examination: Once every 12 monthsLenses: Once every 12 monthsFrames: Once every 12 months
In-NetworkEye Examination: $20 copaySingle Vision Lenses: $20 copayFrames: $150 allowance; 20% off balance over $150Contact Lenses: $150 allowance; 15% off balance over $150
*Reflects In-Network benefits only.
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Life and Accidental Death & Dismemberment InsuranceInsured by Unum
Unum - Basic Life/AD&DEligibility All Full-Time EmployeesBenefit Amount 2x Annual Salary to a max of $400,000
Unum - Voluntary Life / AD&DEligibility All Full-Time Employees & DependentsEmployee BenefitLife and AD&D Benefit Amount Maximum
Up to $500,000($10,000 Increments)
Spouse Life and AD&D Benefit Amount Maximum
Up to $250,000($5,000 Increments)
Child Life and AD&D Benefit Amount Maximum
<14 days: $1,00014 days-6 months: $1,000
>6 months: Up to $10,000 ($1,000 increments)
Short-Term DisabilityInsured by Unum
Unum - STDEligibility All Full-Time EmployeesMaximum Weekly Benefit Amount 60% up to $2,500
Long-Term DisabilityInsured by Unum
Unum - LTDMaximum Monthly Benefit Amount 60% up to $13,500
Minimum Monthly Benefit Amount $100 or 10% of Monthly Benefit
This is not a complete explanation of benefits. The actual plan brochure with complete details is available upon request.
*The information contained herein is subject to the disclosures and disclaimers on the final page of this report/proposal/review.
Employee Assistance Program (EAP)Administered by LifeWorks by Morneau Shepell
The Global Employee Assistance Program (EAP) is a confidential support service that can help you and your dependents solve a wide range of problems and challenges in your lives, at no cost to you. In our increasingly fast-paced world, you may find it challenging to take care of yourself while balancing responsibilities at work with obligations at home. The EAP offers timely, qualified assistance and support to help manage all of life’s complexities. The EAP Care Access Center can be contacted toll-free, 24 hours per day, 7 days per week so that you can access support when you want it.
Voluntary Benefits offered through Unum» Accident
» Critical Illness
» Hospital
Additional Voluntary Benefits» Flexible Spending Accounts
» Health Savings Account
» 401(k) Retirement Savings Plan
» Professional Development
» Wellness Program and Gym Discount
» Legal Services (Administered by ARAG Legal)
» Identity Theft (Administered by InfoArmor)
» Pet Insurance (Administered by Nationwide)
Medical - Per Paycheck DeductionsOAP - HSA PPO (Open Access Plus) HMO Medical
Employee Only $0.00 $0.00 $0.00
Employee + Spouse $176.82 $308.22 $227.59
Employee + Child(ren) $115.54 $216.00 $157.69
Employee + Family $240.18 $418.26 $307.27
Dental - Per Paycheck DeductionsDental PPO Dental HMO
Employee Only $0.00 $0.00
Employee + Spouse $14.68 $3.44
Employee + Child(ren) $18.58 $4.76
Employee + Family $33.51 $9.01
Vision - Per Paycheck DeductionsVision PPO
Employee Only $0.00
Employee + Spouse $1.61
Employee + Child(ren) $1.77
Employee + Family $3.31
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This benefit summary prepared by
This document is an outline of the coverage proposed by the carrier(s), based on information provided by your company. It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and contracts themselves must be read for those details. Policy forms for your reference will be made available upon request.
The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to, your current employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to provide, legal advice. Questions regarding specific issues should be addressed by your general counsel or an attorney who specializes in this practice area.
Coverage Carrier Policy Number Phone OnlineBenefit Advocate Center Employee Concierge
Gallagher(833) 518.4544
M-F: 6:00 am to 6:00 pm (PST)[email protected]
Employee Benefits Website
Gallagher www.myblbenefits.com
Medical PPO/HSA Cigna 3338139 (800) 244.6224 www.mycigna.com
Dental PPO/HMO Cigna 3338139 (800) 244.6224 www.mycigna.com
Vision EyeMed 997816 (866) 939.3633 www.eyemed.com
Life and AD&D Unum 837115 (800) 445.0402 www.unum.com
Short-Term Disability Unum 837116 (877) 851.7637 www.unum.com
Long-Term Disability Unum 837115 (877) 851.7637 www.unum.com
Critical Illness/Accident /Hospital Indemnity
Unum837119
R0795237(800) 635.5597 www.unum.com
FSA / HSA Discovery Benefits (866) 451.3399 www.discoverybenefits.com/employees
Employee Assistance Program (EAP)
LifeWorks(800) 433.7916
24/7 access login.lifeworks.com
Travel Wallet Unum 01-AA-UN-762490Within U.S.: (800) 872.1414
Outside U.S.: [email protected]
Business Travel Accident AIG 9154846Within U.S.: (800) 533.0699
Outside U.S.: (817) 826.7051www.aig.com/us/travelguardassistance.com
Legal ARAG 18349BLA (800) 247.4184www.araglegalcenter.com access code: 18349BLA
Identity Theft InfoArmor (800) 789.2720 www.myprivacyarmor.com
Pet Insurance NationwidePayroll: 6298
Non-Payroll: N7919(877) 738.7874 www.petinsurance.com/blackline
Peer Recognition Kazoo (877) 44.KAZOO [email protected]
Gym Classpass https://classpass.com/corporate/blackline